Medicaid Health Plans and Programs

Most NC Medicaid beneficiaries get Medicaid services through a health plan in NC Medicaid Managed Care.

Health plans help pay for a variety of health care services, such as doctor visits, hospital stays, prescription drugs and preventative care. NC Medicaid health plans provide added services and programs for their members.

A provider network is a group of doctors, hospitals and other health care professionals’ contract with a health plan to provide medical services to its members. These contracted providers are considered “in-network.” In most cases, you must get care from a provider in your health plan’s provider network, such as a primary care provider (PCP). A PCP is a doctor, nurse practitioner or physician assistant. They care for your health, coordinate your needs and refer you to specialists when you need them.

Standard Plans

Most people getting NC Medicaid must get health care services from a Standard Plan. Standard Plans are NC Medicaid Managed Care health plans that offer physical health, pharmacy (prescriptions), care management and basic behavioral health services for beneficiaries.

Who qualifies for a Standard Plan?

• Most families and children
• Pregnant women
• People who are blind or disabled and do not get Medicare
• Federally recognized tribal members or others who qualify for services through Indian Health Service (IHS)

Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans

The Behavioral Health and Intellectual/Developmental Disabilities (I/DD) Tailored Plan (Tailored Plan) is a NC Medicaid Managed Care health plan. It offers physical health, pharmacy (prescriptions), care management and behavioral health services. It is for beneficiaries with serious mental illness, severe substance use disorders, intellectual/developmental disabilities (I/DD) or traumatic brain injuries (TBI). Tailored Plans offer added services for beneficiaries who qualify.

Who Qualifies for a Tailored Plan?

• People who may have a serious mental illness, severe substance use disorder, intellectual/developmental disability or traumatic brain injury
• People who get Innovations waiver services
• People who get Traumatic Brain Injury (TBI) waiver services

To learn more, go to Tailored Plan services.

Eastern Band of Cherokee Indians Tribal Option

The Eastern Band of Cherokee Indians (EBCI) Tribal Option is an Indian Managed Care Entity. As a NC Medicaid health plan, the EBCI Tribal Option to provides managed care for federally recognized Tribal members and other individuals eligible to receive Indian Health Services.

Who qualifies for the EBCI Tribal Option?

Federally recognized tribal members or others who qualify for services through Indian Health Service (IHS) who live in the following counties: Buncombe, Clay, Cherokee, Graham, Haywood, Henderson, Jackson, Macon, Madison, Swain, Transylvania
Find more information on the EBCI Tribal Option website.

Children and Families Specialty Plan

The Children and Families Specialty Plan is a new statewide health plan designed to ensure access to comprehensive physical and behavioral health services for NC Medicaid-enrolled children, youth and families served by the child welfare system. The plan launched Dec. 1, 2025. - ??

Who qualifies for the Children and Families Specialty Plan?

NC Medicaid beneficiaries who are in foster care, receiving adoption assistance and enrolled in the former foster care eligibility will be eligible for the Children and Families Specialty Plan.

This includes:

• Children and youth currently in foster care
• Children and youth receiving adoption assistance
• Young adults under age 26 formerly in foster care at age 18
  • Former foster care children in North Carolina who turned 18 on or before Dec. 31, 2022
  • Former foster care children in any state who turned 18 on or after Jan. 1, 2023
• Minor children of these populations
• Children and youth currently in the EBCI Family Safety Program, or meet the criteria above, will not be auto enrolled in the Children and Families Specialty Plan but will have the option to enroll

For more information visit the Children and Families Specialty Plan webpage.

NC Medicaid Direct

NC Medicaid Direct is North Carolina’s health care program for NC Medicaid beneficiaries who are not enrolled in NC Medicaid Managed Care. It includes care management by Community Care of North Carolina, the primary care case management entity for physical health services.

Local Management Entity/Managed Care Organizations (LME/MCOs) coordinate services for mental health disorders, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI).

Who qualifies for NC Medicaid Direct?

• Children who get Community Alternatives Program for Children (CAP/C) services
• Federally recognized tribal members or others who qualify for services through Indian Health Service (IHS)
• People in the Health Insurance Premium Payment (HIPP) program
• People in the Program for All-Inclusive Care for the Elderly (PACE)
• People who are medically needy
• People who get Community Alternatives Program for Disabled Adults (CAP/DA) services
• People who get Family Planning Medicaid only
• People who get Medicaid and Medicare
• People who may have a mental health disorder, substance use disorder, intellectual/developmental disability (I/DD) or traumatic brain injury (TBI)

For information on health plan enrollment, visit the NC Medicaid Enrollment Broker website.